- Email: [email protected]
HOT SUMMERS, SWOLLEN ANKLES
973
expansion of the consultant grade and is now blocking the progress of many registrars, who have spent two, three, or even more years in the specialty. Radiological registrars in their third year, some of whom have already spent time in other specialties, are worried. It is wasteful for doctors half-trained in radiology to find themselves unable to find a senior post to continue their training up to consultant level. In radiology more registrar posts are needed so that the period of training at this level may be extended, and, urgently, more senior registrar posts, both pre and post FRCR, should be created. In the meantime the number of trainees entering the specialty should be carefully monitored to avoid further wastage and disappointment. The specialty of radiology should be expanded not only on demographic grounds but also because, to be efficient, the National Health Service requires imaging consultants who can advise their clinical colleagues on the shortest and most cost effective route to a
diagnosis.
Department of Radiology, City Hospital, Nottingham NG5 1PB
D. H. ROSE PETER DAVIES
CLINICAL IMMUNOLOGY
SIR,-Dr Reeves has pointed
out
(Sept 24,
p
721)
that the first
priority in the provision of an adequate clinical immunology service should be the training of laboratory-based immunologists. However, we also need immunologically trained physicians whose commitment is primarily clinical. It would be advantageous if at least some of these were not tied to organ-based medical specialties, and there are strong arguments for viewing allergy as a special case. IgE-mediated allergic diseases alone are probably more common than all other immunologically mediated diseases put together. Several organ systems may be involved in atopy, at the same time or sequentially. At present the number of atopics being treated for manifestations of the same allergic process by several different specialists is exceeded only by the number receiving inadequate treatment. Reactions to exogenous substances are commonly caused by non-immunological processes as well as other immunological mechanisms. It is as unreasonable to expect a laboratory-based immunologist to be expert in these, as it is to expect a non-specialist to know whether to refer a patient to a clinical immunologist rather
than, say, a pharmacologist. It is not surprising that so many allergic patients turn for help outside the National Health Service in the absence of adequate care from the orthodox establishment. As a result, they are frequently subjected to unorthodox procedures which are either unproved or are demonstrably ineffective and are sometimes dangerous. In the presence of increasing rigidity in postgraduate specialist training and until "allergy" is recognised as a medical subspecialty, university departments will have to provide the focus for a more system-oriented approach to conditions crossing traditional specialty boundaries. Department of Medicine, University Hospital of South Manchester, Manchester M20 8LR
D. J. PEARSON
ETHICS OF IN-VITRO FERTILISATION
SIR,-Mrs Brahams (Sept 24, p 726) attributes the emotive word "horrific" to us in our submission to the Warnock Committee. This is misleading. The Federation stated that in-vitro fertilisation was unethical. Dr R. G. Edwards has stated that the first baby to have been delivered after this mode of conception would never have been born if he had not spent years working on human embryos. We do not accept that the end justifies the means. World Federation of Doctors who
Respect Human Life,
"Mayfield" 75 St Mary’s Road, Huyton, Merseyside L36 5SR
PEGGY NORRIS, Hon
Secretary
HOT
SUMMERS, SWOLLEN ANKLES
SiR,-The summer of 1983 was one of the hottest recorded in the UK. The following case, one of several admitted to hospital with diuretic complications this summer, is reported as a reminder that a failure to review circumstances and indications for diuretic therapy can have serious consequences, especially in the aged. An 86-year-old arthritic woman was admitted to hospital because of falls. 3 weeks before admission in August, ankle oedema had prompted progressive increase in her frusemide dose (to 240 mg daily) and addition of spironolactone (100 mg daily). She became confused and fell repeatedly. In view of a previous episode of’ confusion associated with urinary sepsis, co-trimoxazole was also prescribed. On admission she looked ill, with cyanosis, hypotension, asterixis, and depressed conscious state. Investigation revealed hyponatraemia (119 mmol/1) and uraemia (102 mmol/l, 600 mg/1). 1 year earlier, her urea had been 10 mmol/l. Treatment with salt and water resulted in a return to her previous ambulant and sensible state, with satisfactory renal function. Diuretics are amongst the most frequently prescribed drugs in the without patient benefit in a large proportion of Co-trimoxazole is a potentially nephrotoxic agent which may have worsened uraemia in our patient. The availability of more potent diuretics increases the likelihood of such at risk patients being exposed to them.3The presence of heatwave conditions4 should stimulate a review of regular diuretic use and possibly temporary cessation or reduction in dosage.
elderly, cases. , probably
Department of Geriatric Medicine, Southampton General Hospital, Southampton SO9 4XY
M. D. DONALDSON R. S. BRIGGS
GASTRIC CANCER AFTER GASTRIC SURGERY: AN INCREASING PROBLEM IN NORWAY
SIR,-Dr Logan and Professor Langman (Sept 17, p 667) conclude that
endoscopic screening for cancer in patients with a history of previous gastric surgery for benign lesions may do more harm than good. Their paper leaves the impression that such cancers constitute a minor health problem, with a rough estimate that "stump cancer" accounts for less than 4% of all gastric cancer mortality. This view accords with Nicholls’ conclusion; 5he reviewed published work up to 1979 and found only 2000 cases. This is in contrast to data from Norway which indicate that the problem of stump cancer has been underestimated. Over the years 1970-79 837 such cases were registered at the Norwegian cancer registry.6 Reporting of all new cases of cancer has been compulsory since 1953, and all gastric carcinomas developing after a previous stomach operation for benign ulcer are specially coded. False positives (ie, miscoded cases including earlier gastric resection for malignancy) accounted for about 2% of the registered cases of stump cancer. The conclusion of the study was that the incidence of stump cancer had rapidly increased during the 1970s while the incidence of gastric cancer had fallen over the same period. In the period 1975-79 stump cancer accounted for about 15% of all gastric cancer among males and 5% among females. There are large geographical differences, with Oslo having the highest percentage (20 - 5). The large difference between the estimated figure of 4% of gastric cancer mortality for the UK and the observed incidence data from Norway may be due to lack of systematic collection of such data in the UK. Other possibilities include differences in indications for surgery, leading to a relatively larger population being at risk in Norway than in the UK. Cancer Registry of Norway, Institute for Epidemiological Research, Norwegian Radium Hospital,
Oslo 3, Norway
EILIV LUND
1. Beck LH. Edema states and the use of diuretics. Med Clin North Am 1981; 65: 291-301. Myers MG, Weingert ME, Fisher RH, Gryfe CI, Shulman HS. Unnecessary diuretic therapy in the elderly. Age Ageing 1982; 11: 213-21. 3. Frohlich ED. Use and abuse of diuretics Am Heart J 1975; 89: 1-3. 4. Lye M, Kamal A. Effects of a heatwave on mortality-rates in elderly inpatients. Lancet 1975; i: 529-31. 5. Nicholls JC. Stump cancer following gastric surgery. World J Surg 1979; 3: 731-36. 6. Lund E. Stumpcancer i Norge 1970-1979. Tidsskr Nor Laegeforen 1983; 103: 765-67. 2.
expansion of the consultant grade and is now blocking the progress of many registrars, who have spent two, three, or even more years in the specialty. Radiological registrars in their third year, some of whom have already spent time in other specialties, are worried. It is wasteful for doctors half-trained in radiology to find themselves unable to find a senior post to continue their training up to consultant level. In radiology more registrar posts are needed so that the period of training at this level may be extended, and, urgently, more senior registrar posts, both pre and post FRCR, should be created. In the meantime the number of trainees entering the specialty should be carefully monitored to avoid further wastage and disappointment. The specialty of radiology should be expanded not only on demographic grounds but also because, to be efficient, the National Health Service requires imaging consultants who can advise their clinical colleagues on the shortest and most cost effective route to a
diagnosis.
Department of Radiology, City Hospital, Nottingham NG5 1PB
D. H. ROSE PETER DAVIES
CLINICAL IMMUNOLOGY
SIR,-Dr Reeves has pointed
out
(Sept 24,
p
721)
that the first
priority in the provision of an adequate clinical immunology service should be the training of laboratory-based immunologists. However, we also need immunologically trained physicians whose commitment is primarily clinical. It would be advantageous if at least some of these were not tied to organ-based medical specialties, and there are strong arguments for viewing allergy as a special case. IgE-mediated allergic diseases alone are probably more common than all other immunologically mediated diseases put together. Several organ systems may be involved in atopy, at the same time or sequentially. At present the number of atopics being treated for manifestations of the same allergic process by several different specialists is exceeded only by the number receiving inadequate treatment. Reactions to exogenous substances are commonly caused by non-immunological processes as well as other immunological mechanisms. It is as unreasonable to expect a laboratory-based immunologist to be expert in these, as it is to expect a non-specialist to know whether to refer a patient to a clinical immunologist rather
than, say, a pharmacologist. It is not surprising that so many allergic patients turn for help outside the National Health Service in the absence of adequate care from the orthodox establishment. As a result, they are frequently subjected to unorthodox procedures which are either unproved or are demonstrably ineffective and are sometimes dangerous. In the presence of increasing rigidity in postgraduate specialist training and until "allergy" is recognised as a medical subspecialty, university departments will have to provide the focus for a more system-oriented approach to conditions crossing traditional specialty boundaries. Department of Medicine, University Hospital of South Manchester, Manchester M20 8LR
D. J. PEARSON
ETHICS OF IN-VITRO FERTILISATION
SIR,-Mrs Brahams (Sept 24, p 726) attributes the emotive word "horrific" to us in our submission to the Warnock Committee. This is misleading. The Federation stated that in-vitro fertilisation was unethical. Dr R. G. Edwards has stated that the first baby to have been delivered after this mode of conception would never have been born if he had not spent years working on human embryos. We do not accept that the end justifies the means. World Federation of Doctors who
Respect Human Life,
"Mayfield" 75 St Mary’s Road, Huyton, Merseyside L36 5SR
PEGGY NORRIS, Hon
Secretary
HOT
SUMMERS, SWOLLEN ANKLES
SiR,-The summer of 1983 was one of the hottest recorded in the UK. The following case, one of several admitted to hospital with diuretic complications this summer, is reported as a reminder that a failure to review circumstances and indications for diuretic therapy can have serious consequences, especially in the aged. An 86-year-old arthritic woman was admitted to hospital because of falls. 3 weeks before admission in August, ankle oedema had prompted progressive increase in her frusemide dose (to 240 mg daily) and addition of spironolactone (100 mg daily). She became confused and fell repeatedly. In view of a previous episode of’ confusion associated with urinary sepsis, co-trimoxazole was also prescribed. On admission she looked ill, with cyanosis, hypotension, asterixis, and depressed conscious state. Investigation revealed hyponatraemia (119 mmol/1) and uraemia (102 mmol/l, 600 mg/1). 1 year earlier, her urea had been 10 mmol/l. Treatment with salt and water resulted in a return to her previous ambulant and sensible state, with satisfactory renal function. Diuretics are amongst the most frequently prescribed drugs in the without patient benefit in a large proportion of Co-trimoxazole is a potentially nephrotoxic agent which may have worsened uraemia in our patient. The availability of more potent diuretics increases the likelihood of such at risk patients being exposed to them.3The presence of heatwave conditions4 should stimulate a review of regular diuretic use and possibly temporary cessation or reduction in dosage.
elderly, cases. , probably
Department of Geriatric Medicine, Southampton General Hospital, Southampton SO9 4XY
M. D. DONALDSON R. S. BRIGGS
GASTRIC CANCER AFTER GASTRIC SURGERY: AN INCREASING PROBLEM IN NORWAY
SIR,-Dr Logan and Professor Langman (Sept 17, p 667) conclude that
endoscopic screening for cancer in patients with a history of previous gastric surgery for benign lesions may do more harm than good. Their paper leaves the impression that such cancers constitute a minor health problem, with a rough estimate that "stump cancer" accounts for less than 4% of all gastric cancer mortality. This view accords with Nicholls’ conclusion; 5he reviewed published work up to 1979 and found only 2000 cases. This is in contrast to data from Norway which indicate that the problem of stump cancer has been underestimated. Over the years 1970-79 837 such cases were registered at the Norwegian cancer registry.6 Reporting of all new cases of cancer has been compulsory since 1953, and all gastric carcinomas developing after a previous stomach operation for benign ulcer are specially coded. False positives (ie, miscoded cases including earlier gastric resection for malignancy) accounted for about 2% of the registered cases of stump cancer. The conclusion of the study was that the incidence of stump cancer had rapidly increased during the 1970s while the incidence of gastric cancer had fallen over the same period. In the period 1975-79 stump cancer accounted for about 15% of all gastric cancer among males and 5% among females. There are large geographical differences, with Oslo having the highest percentage (20 - 5). The large difference between the estimated figure of 4% of gastric cancer mortality for the UK and the observed incidence data from Norway may be due to lack of systematic collection of such data in the UK. Other possibilities include differences in indications for surgery, leading to a relatively larger population being at risk in Norway than in the UK. Cancer Registry of Norway, Institute for Epidemiological Research, Norwegian Radium Hospital,
Oslo 3, Norway
EILIV LUND
1. Beck LH. Edema states and the use of diuretics. Med Clin North Am 1981; 65: 291-301. Myers MG, Weingert ME, Fisher RH, Gryfe CI, Shulman HS. Unnecessary diuretic therapy in the elderly. Age Ageing 1982; 11: 213-21. 3. Frohlich ED. Use and abuse of diuretics Am Heart J 1975; 89: 1-3. 4. Lye M, Kamal A. Effects of a heatwave on mortality-rates in elderly inpatients. Lancet 1975; i: 529-31. 5. Nicholls JC. Stump cancer following gastric surgery. World J Surg 1979; 3: 731-36. 6. Lund E. Stumpcancer i Norge 1970-1979. Tidsskr Nor Laegeforen 1983; 103: 765-67. 2.